Thursday, November 19, 2009

It has been both an exhilarating time for progressives and a bumpy one: the House passed a bill (yay) with a public option (yay). These are victories for progressives, inside and outside of Congress: we made this happen.

But House leaders caved at the last minute to an anti-abortion spoiler, the Stupak-Pitts amendment, and dropped a popular provision proposed by Rep. Dennis Kucinich to protect states that opt for single payer systems from lawsuits under ERISA.

Many of us who both support and desperately need health reform are still trying to make sense of the news of the last week. Advocates and the public need to be unified and energized for the final push to get the best possible bill through the Senate and back through the conference committee with the House.

Here’s what we think all Senators need to hear, and why:

1. The House bill is a major achievement. Preserve and expand on its strong points, including the public option.
There is a lot here for access, quality, affordability and cost control, in fact more than there was in any of the bills that passed through the House Committees. The public option is likely to be more robust than the Congressional Budget Office’s preliminary projection.

2. We need to advance reproductive rights, not retreat.
The anti-abortion amendment is a real threat and a wake-up call.
We can beat it. Many members who voted “yes” on Stupak are on record as pro-choice.
Pro-choice energy can propel reform forward.

3. Protect single payer states from ERISA lawsuits.
It is important to continue to point this out and to organize for single payer, and against the for-profit private insurance industry States will be a far cry further in the march toward single payer if we can win waivers from federal obstacles including ERISA.

The House is still in play; they will be involved in the conference with the Senate, and will vote again on final passage. Our messages to House members depends on how they voted. (See Tables on p. 8):

1. Voted Yes on the bill and No on the Stupak Amendment (178 Democrats): Thank you! You’re the progressive Democratic majority. Help us win the ERISA waiver, and keep what we’ve won.
2. Voted Yes on the bill and Yes on Stupak: Stick with the bill and stick up for women. [For those historically pro-choice: Shame on you for voting Yes on Stupak]
3. Voted No on the bill and No on Stupak: Thanks for opposing Stupak. I’m asking you to stand up for health care reform now and support the bill.
4. Voted No on the bill and Yes on Stupak: We need health care reform now, and need our member of Congress to stick up for women. Will you change your vote and stand up for health reform and for women? [For those historically pro-choice: Shame on you for voting Yes on Stupak]

(for full statement and to see how Menbers voted go to: http://www.centerforpolicyanalysis.org/id62.html)

Thursday, November 12, 2009

Media coverage of the Stupak amendment underestimates its impact on privately-funded abortion. The impact is also being downplayed by the right.

This looks specifically at the language of the amendment to show how it:

1. Certainly eliminates the ability of any health insurance plan participating in the new health insurance exchange from covering abortions for any enrollee, if the plan accepts any enrollee who uses federal funds to pay any part of the premium. This would include the public option, but also any other plans that participate in the exchange.

It also prohibits any plan that would offer “affordability credits” from covering abortions.

2. Could eliminate current practices by 17 states to cover abortion under Medicaid, and prevent other states from doing so.

In addition, it has the following potential effects:

3. Can eliminate the ability of any health insurance plan covered by any part of HR 3962 to cover abortion, depending on the menaning of "any costs."

This could mean any health insurance plan offered through the new health insurance exchanges. The Exchanges, in turn, include both private insurance plans, and a public option.

4. Can eliminate all health insurance funding for abortion, depending on the meaning of "authorizes."

1. Certainly eliminates the ability of any health insurance plan participating in the new health insurance exchange from covering abortions for all enrollees, if the plan accepts any enrollee who uses federal funds to pay any part of the premium. In this way it restricts abortion coverage both to low-income and middle-income women who receive federal funds for subsidies. It also restricts coverage for women who pay entirely with their own funds. This would include the public option, but also any other plans that participate in the exchange.

There is general agreement that the amendment prevents health plans in the new health insurance exchanges from covering abortions, if they will accept women who use federal subsidies to pay part of their premiums.

This prohibition applies to all plans in the exchange. These include the public option, as well as all other private insurance plans in the exchange.

Some people (those earning up to 400% of the federal poverty limit, or about $88,000 for a family of 4) will use federal subsidies (or “affordability credits”) to pay for their premiums. Those people could not buy a health plan that covers abortion through the exchange.

It will apply even though the federal subsidies constitute only a part of the premium, and the rest is paid through private funds.

In addition, any plan that intends to enroll people who accept federal subsidies to help pay part of their premiums will not be able to cover abortion, for anyone who enrolls in the plan. This means women who do not accept federal subsidies, who pay the entire cost of insurance privately, cannot buy an insurance plan that covers abortion through the exchange, if the same health insurance plan covers women who do use the subsidies.

The bill offers women the ludicrous option of buying supplemental abortion plans, as long as they do so outside of the exchange and using their own money. Supplemental abortion plans cannot be purchased using affordability credits, which are public funds. This extra punch assures that in case the Supreme Court balks at outlawing abortion outright for millions of women with employer-provided insurance, women earning up to 400% of the poverty level who take advantage of public subsidies won't be able to use their insurance when they find out their birth control has failed.

All of this is worse than current law. Current law, through the Hyde amendment of 1976, says no federal funds can be used for abortion except if the mother’s life is in danger or in the case of rape or incest. Where the language is ambiguous, the Supreme Court will decide.

"Sec. 265. LIMITATION ON ABORTION FUNDING.(a) IN GENERAL.- No funds authorized or appropriated by this Act (or an amendment made by this Act) may be used to pay for any abortion or to cover any part of the costs of any health plan that includes coverage of abortion, except in the case where a woman suffers from [life-threatening illness related to the pregnancy, or pregnancy is a result of rape or incest]."

2. Could eliminate current practices by 17 states to cover abortion under Medicaid.

17 states now find ways to use state funds to pay for abortion through Medicaid. Medicaid is a program for low-income women which is funded jointly by state and federal dollars. The amendment appears to explicitly prohibit this:

"(b) OPTION TO PURCHASE SEPARATE SUPPLEMENTAL COVERAGE OR PLAN. – Nothing in this section shall be construed as prohibiting any nonfederal entity (including an individual or State or local government) from purchasing separate supplemental coverage for abortions for which funding is prohibited under this section, or a plan that includes such abortions, so long as – (2) such coverage or plan is not purchased using –(B) other nonfederal funds required to receive a federal payment, including a State’s or locality’s contribution of Medicaid matching funds."

3. Could eliminate the ability of any health insurance plan covered by any part of HR 3962 to cover abortion, whether or not it includes people who use federal subsidies to pay for their premiums, depending on the menaning of "any costs."This explicitly could mean any health insurance plan offered through the new health insurance exchanges, both private insurance plans, and the public option.

The amendment says “No funds authorized or appropriated by this act…may be used to …cover any part of the costs of any health plan that includes coverage of abortion.”

It also does not restrict the use of federal funds to premiums. “Any part of the costs of any health plan” could refer to the administrative costs of setting up a health insurance exchange.

There will be people covered in the Exchanges who do not receive any federal subsidies for their premiums. They will pay every penny of the premium out of their own pockets. Some others will pay the premium by a combination of funds from their employers and from themselves.

These people may not be able to buy a plan through the Exchange that covers abortion

4. Can eliminate all health insurance funding for abortion, depending on the meaning of "authorizes."

It says that no funds "authorized or appropriated" by HR 3962 can be used to pay for abortion or to cover the costs of any health plan that covers abortion. It does not limit the application of this prohibition to funds authorized by any section of the bill, to health insurance exchanges, or to the public option. It applies to every word in HR 3962.

It also doesn’t necessarily restrict its application to funds “authorized” by Congress to be paid through federal sources.

Authorization and appropriation are particular acts by Congress to direct public funds to various purposes. That could be what this language means. Which would be bad enough.

The bill also "authorizes" employers and individuals to contribute to health insurance. These are private funds. The funds can be used to buy health insurance entirely privately. Or they could be used to buy insurance within the new health insurance exchanges. It could mean that no health insurance plan purchased as a result of the bill can be used to pay for abortion. None. It is possible that no health plan that covers abortion could be offered through programs created by this bill.

In the case of ambiguity, the Supreme Court could make the final decision.

Monday, November 9, 2009

I think that HR 3962 offers many important improvements over the status quo, in the areas of coverage, affordability and quality, despite significant limitations, I will document these shortly.

The Stupak amendment however is exactly the poison pill it is meant to be. It virtually rolls back women's current legal right to choose abortion. It is an unacceptable political compromise. It cannot stand. Read it here:

http://www.centerforpolicyanalysis.org/id58.html

It says that no funds "authorized or appropriated" by HR 3962 can be used to pay for abortion or to cover the costs of any health plan that covers abortion.

Authorization and appropriation are particular acts by Congress to direct public funds to various purposes. That could be what this language means. Which would be bad enough.

The bill also "authorizes" employers and individuals to contribute to health insurance. These are private funds. It could mean that no health insurance plan purchased under the auspices of the bill can be used to pay for abortion. None. It is possible that no health plan that covers abortion could be offered through programs created by this bill. This may be a debatable interpretation. If it is challenged, the Supreme Court will decide.

It adds that supplemental abortion plans cannot be purchased using affordability credits, which are public funds. This is an extra punch to be sure that just in case the Supreme Court balks at outlawing abortion outright for millions of women with employer-provided insurance, women earning up to 400% of the poverty level who take advantage of public subsidies won't be able to use their insurance once they find out their birth control has failed.

Why are we facing this devil's bargain at the 11th hour in this campaign? Where was the vigorous organizing and mobilization campaign to get the votes needed to pass this bill without dismantling women's hard-fought rights? Was it news to anyone that the Catholic bishops oppose abortion, that they have access to an energized constituency, or that this constituency represents a minority of opinion even among Catholics?

This is not a re-election pitch or a solicitation for funds, which usually prompts messages like these from our leaders. It is also not a proposal for a particular action, People will need to figure out together what to do about this.

Planned Parenthood to their credit suggests writing to the President, calling this the outrage that it is and calling for actual leadership. Good start.

Sunday, November 1, 2009

Now we’re hearing that the public option is too puny to work. Is it true?

Let’s back up a minute, and look at the choices before us right now.

1. No change.2. A reform bill with no public option.3. A reform bill with a public option.

The insurance industry thinks #1 and #2 are just grand. (Despite what they say in public.) They’d like us to believe that #3 is so useless that we should settle for #1 or #2. Here’s why they are wrong:

The existence of a public option creates a wedge for the public sector. The public sector already covers people who are over 65, low-income, in the military, and others. Now it will start slicing into working age Americans. It will have the most bargaining clout to pay lower rates to providers – drug companies, hospitals and doctors - if it includes most of us right away, and can base reimbursement rates on Medicare, plus 5% for wiggle room.

Nancy Pelosi tried to get that. She came up short of the 218 votes needed. After a week of “whipping,” she proposed 2nd best: a public option that will negotiate rates with providers. It won’t save as much money as “Medicare plus 5%” version. Not a great performance by our elected members of Congress, who could’ve sided with the voters who use health care services instead of the industries that provide health care, or by the President of Change, who kept his elegant neck tucked in on that subject.

The Congressional Budget Office and Joint Tax Committee did some pretty quick math:“By 2019, CBO and JCT estimate, the number of nonelderly people who areuninsured would be reduced by about 36 million, leaving about 18 millionnonelderly residents uninsured (about one-third of whom would beunauthorized immigrants). Under H.R. 3962, the share of legal nonelderlyresidents with insurance coverage would rise from about 83 percentcurrently to about 96 percent. Roughly 21 million people would purchasetheir own coverage through the new insurance exchanges, and there wouldbe roughly 15 million more enrollees in Medicaid than the total numberprojected for Medicaid and CHIP combined under current law. (Under thebill, CHIP would no longer exist in 2019.) Relative to currently projectedlevels, the number of people purchasing individual coverage outside of theexchanges would decrease by about 6 million, and the number obtainingcoverage through employers would increase by about 6 million.

“Under the proposal, certain employers could allow all of their workers tochoose among the plans available in the exchanges, but those enrolleeswould not be eligible to receive subsidies via the exchanges (and thus areshown in Table 2 as enrollees in employment-based coverage rather than asexchange enrollees). CBO and JCT expect that approximately 9 millionpeople would obtain coverage in that way in 2019, bringing the totalnumber of people enrolled in exchange plans to about 30 million in thatyear. Roughly one-fifth of the people purchasing coverage through theexchanges would enroll in the public plan, meaning that total enrollment inthat plan would be about 6 million.

“That estimate of enrollment reflects CBO’s assessment that a public planpaying negotiated rates would attract a broad network of providers butwould typically have premiums that are somewhat higher than the averagepremiums for the private plans in the exchanges. The rates the public planpays to providers would, on average, probably be comparable to the ratespaid by private insurers participating in the exchanges. The public planwould have lower administrative costs than those private plans but wouldprobably engage in less management of utilization by its enrollees andattract a less healthy pool of enrollees. (The effects of that “adverseselection” on the public plan’s premiums would be only partially offset bythe “risk adjustment” procedures that would apply to all plans operating inthe exchanges.)”

This is a possible scenario. CBO and JCT are about as smart as anyone, and we need a guidepost in all this, Lord knows. But honestly. We know for sure the public plan will have lower administrative costs and no profits. Will it engage in less utilization management (read, frivolous denial of claims) compared to private insurance plans? We hope so – and we damn well plan to stop the insurance industry from that deadly business plan, too. Will it enroll fewer people, therefore be more expensive, therefore enroll sicker people, therefore be more expensive and enroll fewer people, etc.? Beats me.

Here’s what I’m pretty sure about. I don’t like Options #1 and #2. The public doesn’t either.

I think Option #3 gets us to the next step: coming out of this battle with a victory, and going back to the states to fight for single payer.

Some on the left meet up with the right on this point: they prefer Options #1 and #2. They say the House bill (Option #3) gives more money and power to the insurance industry than they have now. True. But so do Options #1 and #2. In fact, the only way the insurance industry gets less money is to get rid of them. A single payer program funded entirely by the government would accomplish this. We haven’t won the public’s support for that yet, and it’s not just because Max Baucus wouldn’t hold hearings on it.

A bill with Option #3 gives more power to the public sector, and arguably will save some money. It includes the following important benefits for people:

For the first time, most employers will have to contribute to the cost of health insurance. We’re the only system in the world that relies primarily on the workplace to get insurance, but we also have no requirement on employers to actually offer insurance or help pay for it. Right now about 130 million people get insurance through work, but another 27 million workers do not.

It requires individuals to buy insurance, but it provides subsidies to low- and middle-income individuals and families, so they can afford it. Is it affordable enough? Probably something to fight about.

Insurance company abuses will be prohibited: They won’t be able to exclude people with pre-existing conditions, or stop paying for your treatment once it turns out your sick. They’ll have to spend 85% of our premium dollars on actual health care, not executive bonuses and administration.

Costs: gives the government the authority to negotiate for drug prices.

Access: Many more people will qualify for Medicaid, the federal-state program for low-income people. The feds pick up most of the tab. People with COBRA can keep it until the new exchanges kick in, in 2013, and young people can stay on their parents’ plans til age 27. We still need it to start sooner.

Quality: Reform Medicare to encourage better quality of care, eliminate copayments for preventive care, and increase the number of primary care providers.

Is any old thing ok then? I think the victories so far on the public plan are important. We have to fight hard to keep it and strengthen it on the House side, and make sure it gets into the Senate bill in conference. And let’s hold on to each others’ email addresses. We’ll need them for the state single payer fights.